PMB-defaulting schemes could lose accreditation

The Council for Medical Schemes (CMS) has threatened accreditation suspension – or even withdrawal – for those medical schemes and administrators who fail to comply in respect of the provision and payment of prescribed minimum benefits (PMBs).

In a recent circular (No 37 of 2009), newly-appointed CMS acting-registrar and chief executive, Craig Burton-Durham, issued this warning after detailing several non-compliant activities uncovered during a recent compliance evaluation and complaints analysis conducted by the CMS.

The registered rules of medical schemes correctly provide for PMBs, but, Burton-Durham noted, PMBs are often not implemented in terms of these. Among the other anomalies cited were that PMBs are paid for at scheme tariff and not at full cost as provided by the Act (Medical Schemes Act [Act 131 of 1998]), and PMBs are paid at cost only when a member or provider lodges a complaint with the medical scheme.

Also of concern was that short payments or co-payments were being conducted from members’ medical savings accounts.